Documentation and Handover

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ME 2.9.1.1

Detail required for adequate, concise and legally sound documentation in emergency medicine.

ME 2.9.1.2

Use clinical notes to reflect the sequence of events during a patient encounter.

ME 2.9.1.3

Apply understanding of the purpose of a discharge letter and admission documentation by recording clear discharge or admission orders.

ME 2.9.1.4

Document handover of patient care.

ME 2.9.1.5

Convey clinical information in a structured format during handover.

ME 2.9.2.1

Record performance of procedures, including consent and management of complications.

ME 2.9.2.2

Write discharge letters that summarise important, relevant information for community health professionals.

ME 2.9.2.3

Extract salient points relating to the patient's care and present these in a structured manner during handover.

ME 2.9.2.4

Clearly transfer unfinished assessment and management tasks during handover.

ME 2.9.2.5

Clarify outstanding tasks when receiving a handover.

ME 2.9.3.1

Produce succinct patient records and convey clinical reasoning when documenting a patient encounter.

ME 2.9.3.2

Ensure clear documentation of the purpose and findings of a requested patient review.

ME 2.9.3.3

Record advanced care orders, limitations of treatment and their reasons.

ME 2.9.3.4

Reassess and review management of the handover patient.

ME 2.9.4.1

Write a concise and accurate summary of key issues in any patient's care.

ME 2.9.4.2

Ensure that outstanding tasks handed over are relevant to the current emergency encounter.

ME 2.9.4.3

Clarify and focus the clinical reasoning of the clinician providing information during handover.